Tattnall Healthcare Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident had his hand touching her buttocks. [Resident R14's name] was immediately covered, removed, and taken to her room in another hall to be cleaned and examined. SSD visited [Resident R14's name] in her room. The resident showed no signs of distress or anxiety. She was lying in her bed, randomly talking calmly. SSD will visit as needed.An observation on 8/18/2025 at 12:23 pm, revealed Resident R14 was in the facility's main dining room eating her lunch meal. No concerns were noted.A review of Resident R80's admission Record, located in the Profile section of the EMR, revealed Resident R180 was admitted to the facility on [DATE REDACTED] with a diagnosis of chronic obstructive pulmonary disease (COPD). Resident R80 was discharged from the facility on 10/11/2024.A review of Resident R80's quarterly MDS assessment with an ARD of 7/1/2024, located in the MDS tab of the EMR, revealed Resident R80 scored 13 of 15 on the BIMS which indicated he was cognitively intact and had not exhibited any physical, verbal, or other behavioral symptoms towards others.A review of Resident R80's Capacity for Sexual Consent Assessment, dated 7/1/2024 and completed by the SSD, and provided by the facility, indicated, Resident R80 was assessed as having the capacity to consent to sexual intimacy. A review of Resident R80's notes, located in

the Progress Notes section of the EMR, revealed the following entry: 8/23/2024 at 8:00 pm (noted as a late entry created on 8/26/2024 at 12:42 pm), . Nursing observations, evaluation, and recommendations are: A female resident wandered into his room, removed her soiled brief and laid across his bed and he proceeded to rub her buttocks with his hand .A review of the facility's investigation of the 8/23/2024 incident between Resident R14 and Resident R80, provided by the facility, revealed the facility substantiated resident to resident abuse. Included in the facility's investigation were witness statements from staff who witnessed the incident.

A witness statement written by Certified Nursing Assistant (CNA) 1, who was still employed at the facility at

the time of the survey, indicated, On Friday August 23 one of our patient was found in another resident room. She was laying across him with her bottom pants off. I remove her from his bed and walk her to her room. His part was out and he has his hand on her bottom.During an interview on 8/20/2025 at 6:50 am, CNA1 stated on 8/23/2024 between 8:00 PM and 9:00 pm she heard someone yelling in the hallway to come here and she responded. She observed Resident R14 laying across Resident R80 in his bed. CNA1 stated Resident R14 did not have a brief on and she was laying cross ways on the bed with her head hanging off the side of the bed.

CNA1 stated Resident R14's was laying across Resident R80's upper legs, but the resident's genitals were not touching and

she did not recall Resident R80 having his hand on Resident R14's buttocks. CNA1 stated both residents were calm and were not exhibiting any distress. CNA1 explained she assisted Resident R14 out of Resident R80's bed, placed a gown on her, and removed her from the room. CNA1 stated at the time of the incident Resident R14 ambulated independently and she did wander into other resident roomsDuring an interview on 8/19/2024 at 1:39 pm, the SSD stated she worked at the facility on 8/23/2024 when Resident R14 wandered into Resident R80's room. The SSD stated when the incident occurred Resident R14 was able to ambulate independently, wandered constantly, and entered other resident rooms.

The SSD explained that after the incident she went to see Resident R14 and Resident R80 and both residents were calm and

in no distress. The SSD stated she spoke with Resident R80 about the incident and he denied any wrongdoing.During an interview on 8/20/2025 at 10:20 am, the facility's Interim Administrator stated she did not work at the facility when Resident R14 wandered into Resident R80's room on 8/23/2024. The Administrator confirmed the facility's investigation of the incident between Resident R14 and Resident R80 substantiated resident abuse. The Administrator stated the expectation was for the facility to be free of abuse.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Tattnall Healthcare Center

142 Memorial Drive Reidsville, GA 30453

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited TATTNALL HEALTHCARE CENTER in REIDSVILLE, GA for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-08-21.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of TATTNALL HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-20.

Federal health inspectors cited TATTNALL HEALTHCARE CENTER in REIDSVILLE, GA for a deficiency under regulatory tag F-F0645 during a standard health inspection conducted on 2025-08-21.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: PASARR screening for Mental disorders or Intellectual Disabilities

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of TATTNALL HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-20.

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the doors to the outside smoking porch sounded an alarm when the doors were opened. Observations of

the outside grounds around the smoking patio revealed the grounds were fenced and there were three outside gates. Observations of the three outside gates revealed they were unsecured and could be opened by moving the gate's latch to an upward position. The DON was showed which gate it was and thought that Resident R81 exited the facility grounds from the gate on 7/20/2025. She confirmed that all three outside gates were currently not secured. During an interview on 8/20/2025 at 3:00 pm the DON confirmed Resident R81 was an elopement risk and eloped from the facility on 7/20/2025. The DON stated Resident R81 was found unsupervised approximately one eighth of a mile from the facility by a person who was not an employee of the facility.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Tattnall Healthcare Center

142 Memorial Drive Reidsville, GA 30453

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observations, interviews, and record review, the facility failed to serve food that was palatable and hot for three of five residents (R) (Resident R25, Resident R26, and Resident R47) reviewed for food palatability out of a total sample of 33 residents. This failure had the potential for the residents to skip meals and potential for weight loss.

Findings included:1. A review of Resident R25's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/6/2025 and located in the electronic medical record (EMR) under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.During an interview on 8/18/2025 at 11:21 am, Resident R25 stated the food served at the facility did not always taste good. Resident R25 stated the food lacked flavor and could be hotter when served at meals.2. A review of Resident R26's Annual MDS, with an ARD of 7/17/2025 and located in the EMR under the MDS tab, revealed a BIMS score of 13 out of 15, which indicated the resident was cognitively intact.During an interview on 8/18/2025 at 1:40 pm, Resident R26 stated the food was cold when served at meals. Resident R26 specified the breakfast meal was the worst because her eggs, sausage, coffee, pancakes, and toast are cold when served. Resident R26 stated that she had to soak her toast in milk or coffee because it is too hard for her to eat. Resident R26 stated she wanted to be served hot food and hot coffee.3. A review of Resident R47's quarterly MDS, with an ARD of 7/14/2025 and located in the EMR under the MDS tab, revealed a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.During an interview on 8/18/2025 at 11:00 am, Resident R47 stated she did not care for the food served at the facility. Resident R47 specified she ate her meals in her room and her food was not always hot when served and did not always taste good to her.In response to resident complaints about food, a test tray was requested to be sent to the facility's C hallway during the breakfast meal on 8/20/2025.

Observation revealed before the meal tray cart, which contained the test tray, left the kitchen at 8:34 am, resident meals were observed being served on heated plates. Food temperatures on the kitchen tray line were monitored by staff and were at acceptable levels of 140 degrees Fahrenheit (F) and above for the hot foods and below 40 degrees F on cold beverages being served. Toast was being served from a pan on the trayline. The test tray and other resident meal trays were placed on an enclosed tray cart that had no heating element and were delivered to the C hallway at 8:35 am. The last resident's breakfast tray was observed to be served on the C hallway on 8/20/2025 at 8:47 am. At this time, the food and beverages on

the test tray were sampled in the presence of the Dietary Manager (DM). The DM utilized a calibrated facility thermometer to obtain temperatures of the food and beverages served on the test tray. The DM also tasted the food served on the requested test tray. Temperature checks and tasting of the food served on the test tray revealed the following: a. The scrambled eggs on the test tray registered 118 degrees F and were barely warm when tasted. The DM also tasted the scrambled eggs and confirmed the eggs tasted barely warm and needed to be hotter. b. The toast on the test tray registered 80 degrees F and was not warm and was very hard when tasted. The DM also tasted the toast and confirmed it was not warm and was very hard. c. The DM was unable to obtain an internal temperature on the slices of bacon served on the test tray.

When the bacon was tasted it was barely warm. The DM also tasted the bacon and confirmed it was barely warm and needed to be hotter. During an interview on 8/20/2025 at 8:54 am, the DM stated the scrambled eggs, toast and bacon should be hot when served to residents.During an interview on 8/21/2025 at 7:15 pm, the Administrator stated the facility did not have a policy in relation to food palatability.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Federal health inspectors cited TATTNALL HEALTHCARE CENTER in REIDSVILLE, GA for a deficiency under regulatory tag F-F0881 during a standard health inspection conducted on 2025-08-21.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Implement a program that monitors antibiotic use.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of TATTNALL HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-20.

Federal health inspectors cited TATTNALL HEALTHCARE CENTER in REIDSVILLE, GA for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-08-21.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of TATTNALL HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-20.

Federal health inspectors cited TATTNALL HEALTHCARE CENTER in REIDSVILLE, GA for a deficiency under regulatory tag F-F0887 during a standard health inspection conducted on 2025-08-21.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 8 deficiencies cited during this inspection of TATTNALL HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-20.